Methods for safe and effective thrombolysis using sequential administration of tissue plasminogen activator and mutant pro-urokinase

ABSTRACT

Provided herein are methods for safe and effective thrombolysis in therapy for human subjects with symptoms of a potential stroke or acute myocardial infarction (“AMI”) using a sequential administration of a low dose bolus of human tissue plasminogen activator (“tPA”) followed by an infusion of a mutant form of human prourokinase (“proUK”).

CLAIM OF PRIORITY

This application is a divisional of U.S. application Ser. No.15/523,900, filed on May 2, 2017, which is a National Stage under 371 ofInternational Application No. PCT/US2015/058878, filed on Nov. 3, 2015,which claims the benefit of U.S. Provisional Application Ser. No.62/074,374, filed on Nov. 3, 2014. The entire contents of the foregoingapplications are incorporated herein by reference.

SEQUENCE LISTING

The instant application contains a Sequence Listing, which has beensubmitted electronically in ASCII format and is hereby incorporated byreference in its entirety. Said ASCII copy, created on Dec. 20, 2021, isnamed 15702_0006002_Seq_Listing and is 4 KB in size.

TECHNICAL FIELD

This invention relates to methods and compositions for safe andeffective thrombolysis.

BACKGROUND

Thrombosis occurs when a blood clot (thrombus) forms inside a bloodvessel and obstructs the flow of blood through the circulatory system.When a blood vessel is injured, the body uses platelets and fibrin toform a blood clot to seal injured vessels and prevent blood loss. Thisprocess is called hemostasis. Even when a blood vessel is not injured,blood clots may form in the body under certain circumstances. Bloodclots consist largely of aggregated platelets and a mesh of cross-linkedfibrin, which is a natural polymer of fibrinogen in the blood. When athrombus is large enough to reduce the blood flow to a tissue, hypoxiaor anoxia can occur, leading to tissue damage or even tissue death.Depending on the location in the arterial system, i.e., heart, brain, orleg, a thrombus can trigger heart attack, stroke, or peripheralgangrene. In the venous circulation the same process can causethrombophlebitis (deep vein thrombosis) or a pulmonary embolism.Together, these cardiovascular diseases constitute the leading causes ofdeath and disability in industrialized countries.

Thrombolysis mainly involves the use of thrombolytic drugs to dissolvethe disease-causing blood clot and restore blood flow. Thrombolyticdrugs such as tPA and its derivatives in current use function byactivating the proenzyme plasminogen to the protease plasmin, whichdegrades the fibrin mesh in the blood clot and makes the clot soluble,thus restoring blood flow through occluded blood vessels. However, thepresent thrombolytic drugs also induce degradation of hemostatic fibrinthat seals wounds, and generate plasmin in plasma which degrades threeclotting factors, fibrinogen, factor V, and factor VII (hemophilicfactor). Thus, current thrombolytic therapy carries the risk of causingbleeding from hemophilia-like side effects or from the degradation ofhemostatic fibrin. This imposes serious limitations on the number ofpatients eligible for treatment and limits the dose of thrombolytic thatcan be used. As a result, only about 5% of patients with stroke receivetreatment and the efficacy of this treatment is limited.

A stroke can be caused either by a blood clot or a bleeding vessel inthe brain. However, properly diagnosing the specific cause of a strokerequires a CT scan or MRI, which can delay treatment if not immediatelyavailable. Absent such a proper diagnosis, it can be very dangerous toadminister a clot dissolving agent, such as tissue plasminogen activator(“tPA”), if the cause happens to be a bleed rather than a blood clot, asthe results of administering tPA or other thrombolytic agent to apatient who has had a brain bleed can be fatal.

SUMMARY

The present disclosure is based, at least in part, on the discovery thatthe distinct and different specificities of tPA and prourokinase mutant(“proUK mutant or “mproUK”) means that small doses of each incombination induces thrombolysis that is faster and safer, i.e., morespecific and with lower incidence of bleeding complications, e.g., fortreating stoke or acute myocardial infarction (“AMI”), than is possibleusing either one alone (monotherapy) with high doses that achieve amaximum blood clot lysis rate, but with a high risk of bleedingcomplications.

The mproUK can comprise a substitution of histidine for lysine at aminoacid position 300 (Lys300→His) of pro-urokinase (SEQ ID NO:1), referredto herein as “M5.” mproUK, like proUK, is a proenzyme, i.e., theinactive precursor of the active enzyme. It differs from proUK in thatits enzymatic form mutant urokinase or mUK, unlike urokinase (UK), isinhibited by a plasma inhibitor, C1-inhibitor, which additionally to thelower doses necessary, helps to reduce the bleeding side effects seenwith pro-UK, which are due to UK for which there is insufficientinhibitor (plasminogen activator inhibitor-1, PAI-1) in the plasma.

For patients with stroke or AMI, the time needed for thrombolysis andreperfusion is critical to clinical outcome and survival rate. Thismeans that treatment must be safe enough to be given outside thehospital without preliminary diagnostic testing. However, this ispossible only if the hemorrhagic risk is greatly reduced or eliminated,as is the case with the new methods described herein including theadministration of a mini-dose of tPA (e.g., a bolus of less than 5.0 mg,e.g., less than or equal to 4.5 mg, 4.0 mg, 3.5 mg, 3.0 mg, 2.5 mg, or2.0 mg) and low dose of mproUK (e.g., an infusion over 60 to 90 minutes(e.g., 60, 70, 80, or 90 minutes) at a rate of 60 to 120 mg/hour, e.g.,60 to 90 mg/hour, e.g., 60, 65, 70, 75, 80, 85, or 90 mg/hour) incombination.

If the endogenous concentration of C1-inhibitor is insufficient in agiven subject, it can be supplemented in the new methods byadministering an effective amount of a C1-inhibitor, e.g., acommercially available C1-inhibitor such as CINRYZE®, CETOR®, BERINERT®,and RUCONEST®. The C1-inhibitor is an additional precaution in case someconversion of mproUK to mutant UK occurs, but may not be necessary dueto the low dose of mproUK required and the fact that C1-inhibitor is anacute phase reactant, which is automatically elevated by the bodyimmediately after a heart attack or stroke.

Provided herein in a first aspect are methods of treating a subject,e.g., a human patient, with symptoms of a stroke or an acute myocardialinfarction (AMI) at a maximum rate of blood clot lysis and with minimalassociated hemorrhagic side effects, the methods include (a) identifyinga subject who potentially had a stroke or AMI by observing one or moresymptoms of a stroke or AMI without determining the cause of the stroke;and (b) administering to the subject a bolus of a first compositionincluding a mini-dose, i.e., less than 5 mg, of tissue plasminogenactivator (tPA), e.g., 2.0, 2.5, 3.0, 3.5, 4.0, or 4.5 mg of tPA,followed by an intravenous infusion of a second composition including alow dose of pro-urokinase mutant (mproUK) infused over 60 to 90 minutes,e.g., 60, 65, 70, 75, 80, 85, or 90 minutes, at a low dosage rate of 60to 120 mg, e.g., 60, 70, 75, 80, 85, 90, 100, or 120 mg/hour; wherein amaximum clot lysis rate is achieved with minimal associated hemorrhagicside effects.

In some embodiments of these methods the minimal associated hemorrhagicside effects can be determined as a level of fibrinogen degradation inthe subject's blood of less than about 30 percent, e.g., less than27.5%, 25%, 22.5%, or 20% fibrinogen degradation (whereas fibrinogendegradation is about 50 to 80% with monotherapy by either compositionalone). In some embodiments, the maximum clot lysis rate is indicated ashaving been achieved by a Thrombolysis In Myocardial Infarction (TIMI)score of 2 or higher. In other embodiments, the maximum clot lysis rateis indicated as having been achieved by a lysis of about 50% of the massof at least one clot in the subject achieved within 75 minutes, e.g.,within 70, 60, 50, 40, 04 30 minutes.

In these methods, the pro-urokinase mutant can include a substitution ofhistidine for lysine at amino acid position 300 (Lys300→His) ofpro-urokinase. The methods can include starting administration of thesecond composition within five, 10, or 15 minutes after theadministration of the first composition. In some embodiments, the firstcomposition and the second composition together lyse 50% of a mass of atleast one blood clot in the subject in less than one hour.

In certain embodiments, the methods can further include administering tothe subject a third composition including a bolus of C1-inhibitor. Thethird composition can be administered to the subject before or at aboutthe same time, e.g., within 5 minutes, of the administration of thesecond composition. In certain embodiments, the third composition isadministered in an amount sufficient to establish a concentration ofC1-inhibitor that is about 500-750 μg/ml in the subject's blood. In someembodiments, the third composition is a bolus of 500-1500 mg ofC1-inhibitor.

In some of these methods the first composition and the secondcomposition together lyse the blood clots in the presence of theC1-inhibitor with less than 30% fibrinogen degradation when compared tomonotherapy by either tPA or pro-urokinase alone.

In another aspect, the disclosure provides kits that include a firstcomposition in a first container including 2-5 mg of tissue plasminogenactivator (tPA); and a second composition in a second containerincluding 60-120 mg of a pro-urokinase mutant (mproUK) having asubstitution of histidine for lysine at amino acid position 300(Lys300→His) of pro-urokinase. In these kits, the first composition canbe formulated suitable for administration as a bolus and/or the secondcomposition can be formulated suitable for intravenous infusion. Incertain embodiments, the kits further include a third compositionincluding 500-1500 mg of C1-inhibitor, e.g., formulated suitable foradministration as a bolus.

In another aspect, the disclosure provides compositions for use in anyof the methods described herein. In certain embodiments, thecompositions are for use in treating a subject with symptoms of a strokeor acute myocardial infarction (AMI) at a maximum rate of clot lysis andwith minimal associated hemorrhagic side effects. These compositionsinclude a first composition including less than 5 mg of tissueplasminogen activator (tPA), wherein the first composition is or isprepared to be administered to a subject in a dosage regime of a bolus;and a second composition including a pro-urokinase mutant (mproUK),wherein the second composition is or is prepared to be administered to asubject by an intravenous infusion in a dosage regime of 60 to 120mg/hour for 60 to 90 minutes following the administration of the firstcomposition; wherein the subject is identified as potentially having hada stroke or AMI by observing one or more symptoms of a stroke or AMIwithout determining the cause of the stroke prior to administering thefirst composition; and wherein a maximum clot lysis rate is achievedwith minimal associated hemorrhagic side effects. These compositions caninclude all of the features and elements described herein.

The term “treatment” or “therapeutic treatment” means the administrationof one or more pharmaceutical agents to a subject or the performance ofa medical procedure on the body of a subject. The term therapeutictreatment also includes an adjustment (e.g., increase or decrease) inthe dose or frequency of one or more pharmaceutical agents that asubject can be taking, the administration of one or more newpharmaceutical agents to the subject, or the removal of one or morepharmaceutical agents from the subject's treatment plan.

As used herein, a “subject” or “patient” is a human.

An “effective amount” used herein is an amount sufficient to achievethrombolysis without causing significant hemorrhagic or hemophilia-likeside effects. An effective amount can be administered in one or moreadministrations, applications, or dosages. A therapeutically effectiveamount of a pharmaceutical composition (i.e., an effective dosage)depends on the pharmaceutical composition selected.

The “maximum lysis rate” of blood clots is defined herein as a rate oflysis of blood clots at least as fast as what can be achieved bymonotherapy with tPA, proUK or mproUK at a maximally effective dosage(i.e., a dose of the drug at which no faster clot lysis can be achievedby adding additional drug, e.g., a plateau in the clot lysis rate isshown at the maximally effective dosage) without any associatedhemorrhagic side effects. It is important to note that the maximum lysisrate achieved using monotherapy, e.g., with tPA or M5, would causesignificant bleeding in a patient, as indicated, for example, by a levelof fibrinogen degradation of greater than 30%. Surprisingly, the presenttherapeutic methods achieve the maximum lysis rate without hemorrhagicside effects, which can be indicated by a fibrinogen degradation levelof less than 30%, which would not be associated with excess bleeding andwould be clinically acceptable.

Unless otherwise defined, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which this invention belongs. Although methods and materialssimilar or equivalent to those described herein can be used in thepractice or testing of the present invention, suitable methods andmaterials are described below. All publications, patent applications,patents, and other references mentioned herein are incorporated byreference in their entirety. In case of conflict, the presentspecification, including definitions, will control. In addition, thematerials, methods, and examples are illustrative only and not intendedto be limiting.

Other features and advantages of the invention will be apparent from thefollowing detailed description, and from the claims.

DESCRIPTION OF THE DRAWINGS

FIG. 1A is a line graph showing the lysis of fluorescein-labeled plasmaclots by tPA at three doses: 1, 2, or 3 μg/ml. The time used by tPA tolyse 50% of the plasma clots at a saturated dose of 3 μg/ml is 60minutes. FIG. 1B is a bar graph showing remaining fibrinogen at the endof clot lysis, expressed as percentage of the baseline (BL).

FIG. 2A is a line graph showing the lysis of fluorescein-labeled plasmaclots by mproUK (M5) at three doses: 10, 12.5, or 15 μg/ml. The timeused by M5 to lyse 50% of the plasma clots at a saturated dose of 15μg/ml is 50 minutes. FIG. 2B is a bar graph showing remaining fibrinogenat the end of clot lysis, expressed as percentage of the baseline (BL).FIG. 2C is a line graph showing the time used by mproUK (M5) to lysefluorescein-labeled plasma clots was unaffected by the C1-inhibitor (750μg/ml). FIG. 2D is a bar graph showing fibrinogenolysis by M5 wasprevented by the C1-inhibitor (750 μg/ml).

FIG. 3 is a line graph showing maximum clot lysis rate by a combinationof tPA (0.2 μg/ml) and M5 (6 μg/ml) (circle). The combination inducedclot lysis much faster than 0.2 μg/ml tPA (square) or 6 μg/ml M5(triangle) alone. Results are representative of a single experimentperformed in triplicate.

FIG. 4A is a line graph showing clot lysis by a combination of tPA (0.2μg/ml) and M5 (6 μg/ml) (circle). The combination induced clot lysismuch faster than 0.2 μg/ml tPA (square) or 6 μg/ml M5 (triangle) alone.FIG. 4B is a bar graph showing the remaining plasma fibrinogen at theend of clot lysis, expressed as percentage of baseline (BL) fibrinogen.Results are representative of 10 experiments performed in triplicate.

FIG. 5A is a line graph showing maximum clot lysis rate by a combinationof tPA (0.2 μg/ml) and M6 (6 μg/ml) in addition to C1-inhibitor (750μg/ml). The addition of C1-inhibitor to the combination did not inhibitlysis, however it did inhibit lysis by tPA alone.

FIG. 5B is a bar graph showing the remaining plasma fibrinogen at theend of clot lysis, expressed as percentage of baseline (BL) fibrinogen.The C1-inhibitor attenuated fibrinogenolysis.

FIG. 6 is a line graph showing tPA doses higher than 0.2 μg/ml do notfurther enhance clot lysis rate when combined with 6 μg/ml M5.

FIG. 7 is a bar graph showing the average time required to lyse 50% ofthe plasma clots by the combination of 0.2 μg/ml tPA and 6 μg/ml M5(“tPA+M5”), 0.2 μg/ml tPA (“tPA 0.2”), 6 μg/ml M5 (“M5 6”), 15 μg/ml M5(“M5 15”), 3 μg/ml tPA (“tPA 3”). Data are pooled from multipleexperiments (the number of experiments is shown above each bar).

FIG. 8 is a bar graph showing the remaining fibrinogen (% BL) at the endof clot lysis by a combination of 0.2 μg/ml tPA and 6 μg/ml M5 under thedifferent conditions tested, namely, (1) in 2 ml plasma; (2) in 2 mlplasma plus C1-inhibitor (500 μg/ml); and (3) in 5 ml plasma. Increasesin plasma volume naturally decrease fibrinogen degradation (plasmavolumes in human subjects are about 3000 ml on average) and thus the useof a C1-inhibitor is not likely required in vivo, but is useful in invitro studies to better mimic in vivo conditions.

FIG. 9 is a line graph showing that in the absence of a blood clot, nofibrinogenolysis by the combination of 0.2 μg/ml tPA and 6 μg/ml M5occurred for at least 3 hours, which suggests that in the absence of aclot in vivo the combination would also be inactive.

FIG. 10A is a bar graph showing the hematoma volume followingintracerebral hemorrhage in a rat model. Hematoma volume was measured byhemoglobin content at 2 hours post dosing. No significant difference(p=0.5194) was determined between the animals dosed with C1 inhibitor/M5and those dosed with saline/saline. The C1-inhibitor was included sincethe rat is missing this inhibitor of M5/UK.

FIG. 10B is a bar graph showing the histological determination ofhemorrhage volume following intracerebral hemorrhage in a rat model. Nosignificant difference (p=0.6899) in hemorrhage volume was determinedbetween the animals dosed with C1 inhibitor/M5 and those dosed withsaline/saline.

DETAILED DESCRIPTION

The present disclosure is based, at least in part, on the discovery thatthrombolysis can be achieved at a maximum clot lysis rate to achieveincreased blood flow, e.g., at a Thrombolysis In Myocardial Infarction(TIMI) score of 2 or better within about 75 minutes and without theexpected hemorrhagic risk by administering a combination of a mini-doseof tissue plasminogen activator (tPA) and a low dose of pro-urokinasemutant (“pro-UK mutant” or “mproUK”), for example, a mproUK thatcomprises a substitution of histidine for lysine at amino acid position300 (Lys300→His) of pro-urokinase, referred to herein as “M5.” Forpatients with stroke or acute myocardial infarction, the time needed forthrombolysis and reperfusion is critical to clinical outcome andsurvival rate. To make this possible, treatment must also be safe enoughso that patients can be treated before hospitalization. Provided hereinare methods of treating a subject who potentially had a stroke or acutemyocardial infarction.

These methods can be used to treat patients with symptoms of stroke oracute myocardial infarction without the delay caused by time-consumingdiagnostic procedures, thereby enhancing the chances of better clinicaloutcome and survival rate for those patients. Since fibrinolysis can beachieved with mini-doses of tPA and low doses of mproUK in thecombination, non-specific activation of plasminogen and thehemophiliac-like side effects associated with high dose plasminogenactivator regimens can be reduced to minimal levels while stillachieving a maximum clot lysis rate. Also provided herein are kits thatinclude a first composition comprising tPA and a second compositioncomprising mproUK, for use in the methods described herein.

Blood clots are lysed in three steps by the protease plasmin, which isthe activated form of plasminogen. Step 1: plasminogen present in theblood plasma binds to the intact fibrin clot at a specific binding siteon the D-domain that is adjacent to the tPA binding site. tPA activatesplasminogen in this so-called “ternary complex”, which consists offibrin, plasminogen, and tPA, and initiates fibrinolysis. Step 2:plasmin cleaves fibrin preferentially after a lysine residue, creatingcarboxy terminal lysines which represent new plasminogen binding sites.One of these newly created binding sites is a high affinity binding siteconsisting of three C-terminal lysines in the fibrin E-domain. Whenplasminogen binds to this site in the fibrin E-domain, it undergoes aspecial conformational change which enables it to be activated by theintrinsic catalytic activity of pro-UK and mproUK. Step 3: activation ofthe plasminogen by pro-UK/mproUK is accompanied by reciprocal activationof pro-UK/mproUK by plasmin to the enzyme urokinase (UK)/mUK. UK/mUKthen activates the remaining fibrin-bound plasminogen, therebycompleting fibrinolysis (see U.S. Pat. Nos. 5,055,295; 5,472,692;5,626,841; 5,759,542; 7,074,401; 7,837,992; 8,187,592; Pannell, J. Clin.Invest. 81: 853-859, 1988; Zarich, J Am Coll Cardiol 1995; 26: 374-379;Lee, AJNR Am J Neuroradiol 25: 1470-1475, 2004).

The present inventor has discovered how the new combination therapymethods described herein are supported by the steps of fibrinolysisdescribed above. Only tPA can efficiently perform step 1, since only tPAbinds to fibrin, forms a ternary, complex with plasminogen and isspecifically promoted by intact fibrin or by fibrin fragment D.Pro-UK/mproUK does not bind to fibrin in vivo under normal conditions(i.e., it can bind to fibrin only at very high, non-specific doses).Thus, step 2 can be performed efficiently only by pro-UK/mproUK, becauseit has a high substrate affinity for the plasminogen confirmation thatforms when it binds to the fibrin E-domain of degraded fibrin. Fibrinfragment E has no effect on tPA, which does not bind to this domain, andpromotes plasminogen activation only by proUK/mproUK. Thus, step 3 isalso promoted only by pro-UK/mproUK, because, when proUK activatesplasminogen bound to the fibrin E-domain, there is reciprocal activationof proUK to UK by plasmin and UK completes lysis by activating theremaining fibrin-bound plasminogen (by contrast, tPA undergoes noactivation, because its one and two-chain forms have identicalactivities). The only way tPA can perform steps 2 and 3 is at highnon-specific doses that are associated with a high bleeding risk.

The present inventor has discovered that fibrinolysis can be attainedwith a combination of a mini-dose of tPA (only 2-5% of the standard 100mg dose) plus a low dose of a mproUK, e.g., M5 (40-50% of themono-therapy dose) at a maximum rate of clot lysis with a minimal levelof fibrinogen degradation of less than about 30% (e.g., less than about25 or 20%). This tPA-mproUK combination achieves fibrinolysis at amaximum lysis rate that is at least the same as the maximum rate oflysis that can be achieved by monotherapy with either tPA or mproUK at amaximum dose, but with far lower levels of fibrinogen degradation thatare safe and clinically acceptable, as no bleeding risks arise at theselower levels, which is not possible with known monotherapies. Thus, thepresent methods described herein provide thrombolysis that is clearlysuperior to any alleged synergistic combination, which would not includethe newly discovered dual benefits of a maximum blood clot lysis ratewith maximum safety for the patient, i.e., minimal associatedhemorrhagic side effects.

The “maximum lysis rate” of blood clots is defined herein as a rate oflysis of blood clots at least as fast as what can be achieved bymonotherapy with tPA, proUK or mproUK at a maximally effective dosage(i.e., a dose of the drug at which no faster clot lysis can be achievedby adding additional drug, e.g., a plateau in the clot lysis rate isshown at the maximally effective dosage). However, it is important tonote that the maximum lysis rate achieved using monotherapy, e.g., withtPA or M5, would cause significant bleeding in a patient, as indicated,for example, by a level of fibrinogen degradation of greater than 30%.Surprisingly, the “maximum safety” achieved by the new methods describedherein is defined as a fibrinogen degradation of less than 30%, whichwould not be associated with excess bleeding and would be clinicallyacceptable.

For example, the tPA-mproUK combination can lyse 50% of the mass of atleast one blood clot, e.g., multiple blood clots, in less than an hour,e.g., 48, 50, 55, 60, 65, 70, 75, or 80 minutes. The combination alsoallows significantly lower doses to be used, which are far morefibrin-specific, safer, and more economical. mproUK, e.g., M5, is usedinstead of native pro-UK because mproUK is more stable in plasma attherapeutic doses and remains in its fibrin-specific pro-enzyme form,while native pro-UK tends to spontaneously convert into urokinase, whichis a non-specific plasminogen activator that can cause bleedingcomplications. This is why pro-UK was denied market approval by the EMEAin Europe, following which its development also ceased in this country.

As shown in the examples below, when incubated in plasma in the absenceof a blood clot, the very lose doses used in the tPA-mproUK combinationdo not induce any degradation of fibrinogen, and it is thus expectedthat the same combination will have little or no effect on coagulationor wound healing. In addition, since M5 is a proenzyme and requiresfibrin for its activation, it is expected to be safe even in thepresence of bleeding, e.g., during a hemorrhagic stroke. Furthermore,C1-inhibitor, which is available as a pharmacological agent, can be usedto quench any non-specific activity of any mUK that may be formed duringfibrinolysis (Pannell, J Thromb Haemost. 5(5):1047-54, 2007), e.g., intests done in vitro as well as in therapy in vivo, if required. ThisC1-inhibitor effect is not shared by UK, and is unique to the proUKmutant.

Clinically, the tPA-mproUK combination therapy can be used to treatpatients with stroke or heart attack symptoms without the delay causedby time-consuming diagnostic procedures, which are currently mandatorydue to the significant bleeding risk associated with tPA in treatingstroke. Treatment can be administered on suspicion or in the ambulance.Since time is of the essence for survival and clinical outcome of thosepatients, the combination therapy offers better efficacy and outcomethan tPA as a monotherapy, which is the only therapy currently approvedand available. The therapeutic benefit of tPA monotherapy in treatingstroke remains controversial, and its authorization has been recentlyquestioned (Sandercock P, Lancet. 2014 Aug. 23; 384(9944):660-1). ThemproUK preferentially activates plasminogens in the “bad” occlusiveclots while sparing plasminogens in the “good” wound-sealing clots.Therefore, there is little risk of opening up a hemostatic site. Bycontrast, tPA targets such site which are made up of intact fibrin, asdescribed above in Step 1 of fibrinolysis. Free plasminogen in theplasma is also protected by the action of C1-inhibitor, so there is lessrisk of inducing a hemophilia-like state.

The maximum clot lysis rate of the present methods can be determined invivo can be determined, for example, by standard techniques forassessing blood vessel recanalization. For example, the grade of bloodvessel occlusion can be assessed in analogy to the Thrombolysis InMyocardial Infarction (TIMI) score, wherein a TIMI score of 0 iscomplete occlusion, TIMI of 1 is minimal perfusion, TIMI of 2 is partialflow (recanalization), and a TIMI score of 3 is complete flow. The TIMIstudy group developed this grading scale for coronary blood flow basedon visual assessment of the rate of contrast opacification of theinfarct artery (see, e.g., The TIMI Study Group. The Thrombolysis inMyocardial Infarction (TIMI) trial: phase I findings. N Engl J Med.1984; 33:523-530; and The TIMI Study Group. Comparison of invasive andconservative strategies after treatment with intravenous tissueplasminogen activator in acute myocardial infarction: results of theThrombolysis in Myocardial Infarction (TIMI) phase II trial. N Engl JMed. 1989; 320:618-627, which are incorporated herein by reference fortheir description of the TIMI grading scale).

The TIMI flow grade has become the standard for semi-quantitativeevaluation of myocardial perfusion before and after coronary reperfusiontherapies as well as for determining therapies for stroke. Both TIMIflow grades 2 and 3 have been considered indicative of successfulreperfusion. Thus, as used herein, a maximum clot lysis rate is expectedto be associated in human subjects or patients with achieving a TIMIscore of 2 or better within about 75 minutes or less, e.g., within 70,65, 60, 55, 50, 45, 40, 35, or 30 minutes.

Plasminogen Conformations and Distinction between “Good” and “Bad” BloodClots

Plasminogen can take on at least three different conformations beforeconverting to active plasmin. The first conformation is the native“closed” conformation, i.e., unbound to any fibrin, and plasminogenexists in the blood in this first conformation. Urokinase can activateplasminogen in this first conformation and may cause non-specifichemorrhagic diathesis, i.e., a hemophilia-like state. Since pro-UK attherapeutic doses is unstable and readily converts to urokinase attherapeutic concentration, pro-UK can also cause hemophilia-likeside-effects.

When bound to fibrin, plasminogen can adopt two or three different“open” conformations, providing a basis to distinguish the goodwound-healing clots from bad occlusive clots. The first of these is theplasminogen conformation that takes place when plasminogen binds to aninternal lysine in the D-domain of intact fibrin. The second of these isthe plasminogen conformation that occurs when plasminogen binds to thethree C-terminal lysines on fibrin fragment E, which is exposed onlyafter some fibrin degradation as described above in Step 2 offibrinolysis.

When hemostatic fibrin forms to seal an injury, it acts like a bandageand causes no interference with blood flow. The intact fibrin in such ahemostatic clot has only an internal plasminogen-binding site located inthe D-domain, which induces the first of these fibrin-boundconformations. In this conformation, plasminogen is susceptible toactivation by tPA, whose fibrin binding site is adjacent, but not bypro-UK, which does not bind to fibrin and has substrate binding due tothe second conformation induced by the fibrin E-domain.

When a thrombus forms in a blood vessel, it impedes or arrests bloodflow and triggers the local release of tPA from the occluded bloodvessel wall and leads to fibrin degradation. Fibrin degradation exposesa new plasminogen-binding site on fibrin fragment E. Plasminogen bindsto this new binding site on fibrin fragment E. Pro-UK preferentiallyactivates plasminogen bound to fibrin fragment E.

Utilization of this important distinction between the “good” and the“bad” fibrin clots can effectively achieve thrombolysis while protectinghemostatic plugs that seal injuries. Pro-UK mutant has the same mode ofaction as pro-UK.

A third fibrin-bound plasminogen conformation exist when plasminogenbinds to a single C-terminal site, believed to be on the fibrin gammachain.

Tissue Plasminogen Activator

Tissue plasminogen activator is a serine protease stored in endothelialcells lining the blood vessel wall. When a thrombus occludes a bloodvessel, tPA is released from the blood vessel wall and lyses fibrinclots.

Currently most therapeutic thrombolysis is performed using tissueplasminogen activator (tPA) and its derivatives, however, tPA can causehemorrhagic side effects. For example, tissue plasminogen activator(tPA) at a dose of 150 mg has been shown to induce superior coronarythrombolysis, but has been accompanied by an unacceptable incidence ofintracranial hemorrhage, obliging the adoption of a less effective doseof 100 mg (Braunwald, J Amer Coll Cardiol. 9: 467, 1987; Grossbard, JAmer Coll Cardiol. 9:467, 1987). In comparative clinical trials in acutemyocardial infarction (AMI) patients, results with percutaneous coronaryintervention (PCI) were significantly better than intravenousadministration of tPA, although PCI is more costly, technicallydemanding, and time-consuming. This clinical outcome was surprising, butcan be explained by the following tPA properties: (1) the therapeuticdose of tPA is limited by the intracranial hemorrhage complications; and(2) tPA's efficacy is undermined by a relatively high coronaryrethrombosis rate, which is associated with hematological evidence ofthrombin generation (Verheugt, J Am Coll Cardiol 1996, 27: 766-773;Gurewich, Circulation 1993, 87: 1759-1761; Rapold, Blood 1991, 78:1490-1495; Gulba, Lancet 1988, 2: 97; Gulba, Circulation 1991, 83:937-944).

In ischemic stroke, a further dose reduction was required due to a 20%incidence of intracranial hemorrhage complications when administeringtPA at doses equivalent to those used in AMI (Hacke, JAMA 1995, 274:1017-1025). The use of heparin, which is used with tPA in AMI, isprecluded in stroke, as reocclusion rates of 14-31% have been reported(Alexandrov, Neurology 2002, 59: 862-867; Rubiera, Stroke 2005, 36:1452-1456; Saqqur, Stroke 2007; 38: 69-74). The net result has been thatonly about 2-5% of patients with ischemic stroke are treated with tPA inthe United States (Kleindorfer, Stroke 2008; 39: 924-928).

tPA-induced bleeding is believed to be primarily related to lysis ofhemostatic fibrin needed to repair injury sites in the vessel wall,which are usually occult and unpredictable, but tPA dose-dependent.proUK/M5 spares these sites due its different mode of action, asdescribed above.

Pro-Urokinase and Pro-Urokinase Mutants

Pro-urokinase (pro-UK)(SEQ ID NO:1) is less well-known as a thrombolyticdrug, but Phase 3 clinical studies in acute myocardial infarction havebeen completed (Michels R, J Thromb Thrombolysis 1995, 2: 117-124; PRIMITrial Study Group. Lancet 1989, 1: 863-867; Tebbe U, J Am Coll Cardiol1998, 31: 487-493). Pro-UK induced little (5%) or no coronaryrethrombosis and no hematological evidence of thrombin generation inthese studies (PRIMI Trial Study Group. Lancet 1989, 1: 863-867; Weaver,J Am Coll Cardiol 1994, 241: 242-1248). Unfortunately, at therapeuticdoses, pro-UK became vulnerable to spontaneous activation into theenzyme form, two-chain urokinase (tcUK), in plasma. When this occurred,it incurs a bleeding risk, and for this reason, marketing approval wasdenied and pro-UK development was abandoned in the West.

The instability of pro-UK was related to its relatively high intrinsiccatalytic activity. Structure-function studies revealed the chargedresidues in a flexible loop consisting of amino acid residues 297-313 inthe catalytic domain are responsible for this activity. Mutagenesis inthe flexible loop region resulted in modulation of the intrinsicactivity of pro-UK (SEQ ID NO:1). Exemplary pro-UK “flexible loop”mutants with reduced intrinsic catalytic activity are described in U.S.Pat. No. 5,472,692 (incorporated herein by reference in its entirety),such as Gly299→Ala mutant, Lys300→His mutant (known as “M5” or “M5mutant”), Lys300→Ala mutant, and Glu301→His mutant.

One of these pro-UK “flexible loop” mutants, M5 (Lys300-His), has beentested both in vitro and in vivo, and was shown to dissolve blood clotsmuch faster than native pro-UK (Liu et al., Circulation Research,90:757-763, 2002). The intrinsic activity of the single-chain M5 mutantis five-fold lower than pro-UK, so M5 is more stable in blood thannative pro-UK and less likely to spontaneously convert into activeenzyme form and cause hemophilia-like side effects (Liu, Biochemistry1996, 35: 14070-14076). The activity of the two-chain enzymatic form ofmproUKs, e.g., M5, and the mode of action of mproUKs, e.g., M5, remainthe same as native pro-UK (Sun Z, J Biol Chem 1997, 272: 23818-23823;Liu, Circu. Res. 2002, 90: 757-763). mproUKs like M5 possess anothersuperior property; they can be inhibited by endogenous plasmaC1-inhibitor, providing protection against non-specific side effectswithout interfering with fibrinolysis by mproUK (Gurewich, J ThrombosHaemost, 2006, 4: 1559-1565; Pannell, J Thromb Haemost, 2007, 5:1047-1054; Gurewich, Thromb Haemost, 2009, 102: 279-286). Importantly,mproUKs such as M5 do not show any hemorrhagic side effects normallyassociated with thrombolytic agents as described in U.S. Pat. No.7,074,401 (incorporated herein by reference in its entirety). Inaddition, mproUKs such as M5 can be synthesized according to the methodsdescribed in U.S. Pat. No. 7,070,958 (incorporated herein by referencein its entirety).

M5 and other mproUKs are expected to be safe for human administration,because (1) they are essentially a natural human protein (99.8%similarity to native pro-UK), (2) they are free of antigenic(immunologic) reactions, and (3) naturally occurring human pro-UK andrecombinant human pro-UK from E. coli have already been safelyadministered to about 5,000 human patients in Phase III clinicalstudies.

Combination Therapy of Low Dose tPA and mproUK By utilizing thecomplementary mechanism of action of tPA and pro-UK on plasminogenaction, the present inventor has demonstrated that fibrinolysis at amaximum clot lysis rate can be attained with a combination of amini-dose of tPA (at 2-5% of the standard 100 mg dose, e.g., 1.0, 2.0,2.5, 3.0, 3.5, 4.0, or 4.5 mg bolus) plus an infusion of mproUK, e.g.,M5, (at 40-50% of monotherapy dose, e.g., 60 to 120 ug/ml infused over60-90 minutes) giving a maximum clot lysis rate, which is at least asfast as the maximum clot lysis rate that can be achieved by monotherapywith either tPA or mproUK alone at their maximal effective dose (FIGS.1A to 5B). For example, the tPA-mproUK combination can lyse 50% of themass of blood clots in less than an hour, e.g., 48 minutes, on average(see FIG. 7, tPa+MF). Although tPA and mproUK (M5) alone can achievesimilar lysis time at very high doses, e.g., tPA at 3 μg/ml or mproUK(M5) at 15 μg/ml (FIG. 7), non-specific activation of plasminogen andresultant fibrinogen degradation of about 77% for M5 (see FIG. 2B) andabout 80% for tPA (see FIG. 1B) can occur at those doses and causesignificant and clinically unacceptable hemophiliac-like side effects.

mproUK such as M5 is used instead of native pro-UK, because mproUK ismore stable in plasma and remains in proenzyme form while native pro-UKtends to spontaneously convert into urokinase and cause hemophiliac-likeside effects. Thus, the maximum clot lysis rate can be achieved by thetPA-mproUK combination with only a fraction of the monotherapy doses oftPA and mproUK.

When incubated in plasma in the absence of a blood clot, the tPA-mproUKcombination does not induce any degradation of fibrinogen (FIG. 9), andthus is expected to have no effect on coagulation and wound healing invivo. Furthermore, CT-inhibitor can be used to quench any non-specificactivity of mUK (the enzymatic form of mproUK) in plasma (FIGS. 2D and6), adding further protection against bleeding complications.

Clinically, the tPA-mproUK combination therapy can be used to treatpatients with stroke or heart attack symptoms without the delay causedby time-consuming diagnostic procedures. Provided herein are methods oftreating a subject with symptoms of stroke or acute myocardialinfarction by (a) identifying a subject who potentially had a stroke oracute myocardial infarction by observing one or more symptoms withoutdetermining the underlying cause of the stroke or acute myocardialinfarction; and (b) administering to the subject a bolus of a firstcomposition comprising 5 mg or less of tPA followed by an infusion of asecond composition of mproUK at a rate of 60 to 120 mg/hour infused over60 to 90 minutes. The second composition can be administered about 5,10, or 15 minutes after the administration of the first composition. Thefirst composition and the second composition are administered in anamount to lyse any blood clot that causes the symptoms of stroke oracute myocardial infarction at a maximum lysis rate. The firstcomposition can include 2 to 5 mg of tPA, e.g., about 2 mg, about 2.5mg, about 3 mg, about 3.5 mg, about 4 mg, about 4.5 mg, about 5 mg. Thesecond composition that includes an mproUK like M5 can be administeredby intravenous infusion. The intravenous infusion of mproUK like M5 canbe performed at a dose of about 60-120 mg/hour (e.g., 60-100, 70-90, or75-85 mg/hour) for 60, 70, 80, or 90 minutes.

The methods described herein can be used to treat stroke. A stroke canbe ischemic or hemorrhagic. Ischemic stroke is caused by a thrombusobstructing blood flow, while hemorrhagic stroke is caused by a brokenblood vessel. About 85% of the time, a stroke is ischemic, e.g., causedby a blood clot, and is therefore amenable to treatment by athrombolytic agent. The timing of reperfusion after an ischemic strokeis critical, because the longer the brain cells are without oxygenatedblood, the more brain cells are lost. However, it is difficult and timeconsuming to fully diagnose the cause of a stroke, yet an accuratediagnosis is critical for treatment with currently availablethrombolytic agents due to the high risk of hemorrhagic side effects.Administering a thrombolytic agent to an ischemic stroke patient may bea proper therapy, but administering the same thrombolytic agent to ahemorrhagic stroke patient will exacerbate the problem and can kill thepatient. Although it takes time to confirm a diagnosis, the basicsymptoms of stroke exhibited by a person (such as sudden onset ofone-sided paralysis) can be readily determined by one skilled in themedical field, such as an EMT, a nurse, or a doctor, or even a laypersonwith minimal training.

A subject with symptoms of stroke can be treated using the methodsdescribed herein by administration of a bolus of a low dose of tPAfollowed by an infusion of mproUK. The very low dose of tPA in thecombination reduces potential hemorrhagic risk. Since the tPA in thecombination is a mini-dose and the mproUK can lyse a thrombus but sparehemostatic fibrin, the combination can be used to treat patients with apossible ischemic stroke safely with little risk of aggravating bleedingin the brain. Thus, it is possible to initiate treatment in theambulance on the basis of a clinical suspicion of the diagnosis.

The methods described herein can also be used to treat heart attack,e.g., acute myocardial infarction. A heart attack occurs when one of thecoronary arteries is blocked, e.g., by a blood clot. The timing ofreperfusion after a heart attack is critical, because the longer theheart muscle is without oxygenated blood, the more muscle cells aredamaged or lost. The present treatment of choice is by catheterizationand angioplasty, which requires hospitalization, an availablecatheterization room and staff at the ready. This delays treatment andcarries a high cost. This first one hour after a coronary occlusion hasbeen called the “Golden Hour,” because it is the time during which themaximum salvage of heart muscle and the maximum reduction in mortalityis possible. Pretreatment with tPA to gain time before catheterizationhas been generally abandoned since multiple studies have shown that tPAsignificantly increase the complication rate with catheterization.

A subject with symptoms of a heart attack can be treated byadministration of a bolus of a low dose of tPA followed by an infusionof an mproUK such as M5 as described herein. Experience has shown thatpretreatment with pro-UK is not associated with post catheterizationcomplication, so that pretreatment with the combination should be welltolerated and may also reduce the need for the subsequentcatheterization.

C1-Inhibitor

C1-inhibitor is a 104 KD serine protease inhibitor with a normal plasmaconcentration of about 250 μg/ml and a half-life of about 28 hours.Deficiency of this protein has been associated with a disease calledhereditary angioedema. C1-inhibitor has long been administeredclinically for the treatment of hereditary angioedema. Commerciallyavailable C1-inhibitors include CINRYZE®, CETOR®, BERINERT®, andRUCONEST®.

The active enzymes two-chain UK or mUK generated during fibrinolysis areeventually released into the plasma where plasminogen activation becomesa liability. Quenching this activity requires plasma inhibitors. Asdescribed in U.S. Pat. No. 7,837,992 (incorporated herein by reference),an inhibitor complex of C1-inhibitor appeared within minutes of theincubation of enzyme mUK with human or dog plasma. C1-inhibitor ispresent endogenously in human body and can be supplementedpharmacologically. The endogenous C1-inhibitor was shown to be veryeffective in quenching activity of mUK, e.g., tcM5, but not UK activity(Gurewich V, J Thrombos Haemost, 2006; 4: 1559-1565; Pannell R, J ThrombHaemost, 2007; 5: 1047-1054; Gurewich, Thromb Haemost, 2009; 102:279-286). As shown in U.S. Pat. No. 7,837,992, the C1-inhibitor byinhibiting mUK effectively stabilized the mproUK like M5 in plasma andallowed a higher concentration of mproUK like M5 to be tolerated withoutcompromising fibrin-specificity.

The methods of treating a subject with symptoms of stroke or acutemyocardial infarction disclosed herein can further includeadministration of a third composition comprising a C1-inhibitor to thesubject. The C1-inhibitor can be administered as a bolus in an amountsufficient to establish a concentration of C1-inhibitor in the subject'splasma that is within the range of two to three times above normalphysiological level of C1-inhibitor (about 250 μg/ml), i.e., about500-750 μg/ml. For example, the third composition can include 500-1500mg of C1-inhibitor. In some embodiments, the third composition can beadministered to the subject before the administration of the secondcomposition. In some embodiments, the third composition can beadministered to the subject simultaneously with the second composition.

Pharmaceutical Compositions, Dosage Regimens, and Methods ofAdministration

Pharmaceutical compositions provided herein can include specific dosagesof tPA and a pro-UK mutant such as M5 as active ingredients. The activeingredient of a pharmaceutical composition, e.g., tPA or mproUK, can beformulated for delivery by intravenous injections.

Methods of formulating suitable pharmaceutical compositions are known inthe art, see, e.g., Remington: The Science and Practice of Pharmacy,21st ed., 2005; and the books in the series Drugs and the PharmaceuticalSciences: a Series of Textbooks and Monographs (Dekker, NY). Forexample, solutions or suspensions used for parenteral administration caninclude the following components: a sterile diluent such as water forinjection, saline solution, fixed oils, polyethylene glycols, glycerin,propylene glycol or other synthetic solvents; antibacterial agents suchas benzyl alcohol or methyl parabens; antioxidants such as ascorbic acidor sodium bisulfite; chelating agents such as ethylenediaminetetraaceticacid EDTA); buffers such as acetates, citrates or phosphates and agentsfor the adjustment of tonicity such as sodium chloride or dextrose. pHcan be adjusted with acids or bases, such as hydrochloric acid or sodiumhydroxide. The parenteral preparation can be enclosed in ampoules,disposable syringes or multiple dose vials made of glass or plastic.

Pharmaceutical compositions suitable for injection can include sterileaqueous solutions (where water soluble), dispersions, and sterilepowders for the extemporaneous preparation of sterile injectablesolutions or dispersion. For intravenous administration, suitablecarriers include physiological saline, bacteriostatic water, CremophorEL™ (BASF, Parsippany, N.J.), or phosphate buffered saline (PBS). In allcases, the composition must be sterile and should be fluid to the extentthat easy syringability exists. It should be stable under the conditionsof manufacture and storage and must be preserved against thecontaminating action of microorganisms such as bacteria and fungi. Thecarrier can be a solvent or dispersion medium containing, for example,water, ethanol, polyol (for example, glycerol, propylene glycol, andliquid polyethylene glycol, and the like), and suitable mixturesthereof. The proper fluidity can be maintained, for example, by the useof a coating such as lecithin, by the maintenance of the requiredparticle size in the case of dispersion and by the use of surfactants.

Prevention of the action of microorganisms can be achieved by variousantibacterial and antifungal agents, for example, parabens,chlorobutanol, phenol, ascorbic acid, thimerosal, and the like. In manycases, it will be preferable to include isotonic agents, for example,sugars, polyalcohols such as mannitol, sorbitol, and sodium chloride inthe composition. Sterile injectable solutions can be prepared byincorporating the active compound in the required amount in anappropriate solvent with one or a combination of ingredients enumeratedabove, as required, followed by filtered sterilization. Generally,dispersions are prepared by incorporating the active compound into asterile vehicle, which contains a basic dispersion medium and therequired other ingredients from those enumerated above. In the case ofsterile powders for the preparation of sterile injectable solutions, thepreferred methods of preparation are vacuum drying and freeze-drying,which yield a powder of the active ingredient plus any additionaldesired ingredient from a previously sterile-filtered solution thereof.

The pharmaceutical compositions can be included in a container, pack, ordispenser together with instructions for administration.

Dosage regimens can be adjusted to provide the optimum therapeuticresponse. See e.g., Physicians' Desk Reference, 63rd edition, ThomsonReuters, Nov. 30, 2008. For example, Dosage, toxicity and therapeuticefficacy of the therapeutic compounds can be determined by standardpharmaceutical procedures in cell cultures or experimental animals,e.g., for determining the LD50 (the dose lethal to 50% of thepopulation) and the ED50 (the dose therapeutically effective in 50% ofthe population). The dose ratio between toxic and therapeutic effects isthe therapeutic index and it can be expressed as the ratio LD50/ED50.Compounds which exhibit high therapeutic indices are preferred. Whilecompounds that exhibit toxic side effects may be used, care should betaken to design a delivery system that targets such compounds to thesite of affected tissue in order to minimize potential damage touninfected cells and, thereby, reduce side effects.

The data obtained from cell culture assays and animal studies can beused in formulating a range of dosage for use in humans. The dosage ofsuch compounds lies preferably within a range of circulatingconcentrations that include the ED50 with little or no toxicity. Thedosage may vary within this range depending upon the dosage formemployed and the route of administration utilized. For any compound usedin the method of the invention, the therapeutically effective dose canbe estimated initially from cell culture assays. A dose may beformulated in animal models to achieve a circulating plasmaconcentration range that includes the IC50 (i.e., the concentration ofthe test compound which achieves a half-maximal inhibition of symptoms)as determined in cell culture. Such information can be used to moreaccurately determine useful doses in humans. Levels in plasma may bemeasured, for example, by high performance liquid chromatography.

The tPA bolus can include 2-5 mg of tPA, e.g., about 2 mg, about 2.5 mg,about 3 mg, about 3.5 mg, about 4 mg, about 4.5 mg, or about 5 mg. Theintravenous dose of mproUK, e.g., M5, can be 60-120 mg/hour (e.g.,60-100, 70-90, or 75-85 mg/hour) for 60, 65, 70, 75, 80, 85, or 90minutes. The C1-inhibitor can be administered as a bolus in an amountsufficient to establish a concentration of C1-inhibitor in the subject'splasma that is about 500-750 μg/ml. For example, the C1-inhibitor boluscan include 500-1500 mg of C1-inhibitor.

For patients with stroke or acute myocardial infarction, the time neededto reperfusion is critical to survival and clinical outcome. Thesefindings suggest that a combination of mini-dose tPA and M5 can achievetherapeutic thrombolysis in a safer and more effective way. Thus,patients with stroke or acute myocardial infarction can be treated witha combination of tPA and M5 with little or no delay.

Efficacy of thrombolysis is defined by the rate of lysis. However, theclinical utility requires that efficacy be divided by the incidence ofbleeding complications from that rate. With the combination therapydescribed herein, the evidence is that there is no maximum clinicalutility, since the optimum combination induces a maximum rate of lysiswithout significant fibrinogen degradation (see Pannell et al., PLOSONE, DOI:10.1371/journal.pone.0122018 Mar. 26, 2015, which isincorporated herein by reference in its entirety). This makes for a farsuperior clinical utility index, in fact it gives the maximum utilityindex possible, i.e., the maximum clot lysis rate possible forplasminogen activators without side effects.

Kits

Also provided herein are kits that include at least a compositioncomprising tissue plasminogen activator (tPA) in one container andanother composition comprising an mproUK, e.g., M5, in a separatecontainer. The kits are used to carry out the therapeutic methodsdescribed herein. The first composition can be formulated suitable foradministration as a bolus, and can include 2-5 mg of tPA. The secondcomposition can be formulated suitable for intravenous infusion. Thesecond composition can include 60-120 mg (e.g., 60, 65, 70, 75, 80, 85,or 90 mg) of the pro-UK mutant, for infusion over a time period of 60-90minutes. The kit can also include a third composition comprisingC1-inhibitor. The third composition can be formulated suitable foradministration as a bolus, and can include about 500-1500 mg ofC1-inhibitor.

Kits generally include the following major elements: packaging, reagentscomprising binding compositions as described above, optionally acontrol, and instructions. Packaging can be a box-like structure forholding a vial (or number of vials) containing the compositions, andinstructions for use in a method described herein. Individuals skilledin the art can readily modify the packaging to suit individual needs.

Compositions and kits provided herein can be used in accordance with anyof the methods (e.g., treatment methods) described above. For example,compositions and kits containing a composition comprising tPA andanother composition comprising a pro-UK mutant, e.g., the M5 mutant, canbe used to treat stroke, heart attack, or other cardiovascular diseasescaused by a thrombus such as peripheral gangrene. Those skilled in theart will be aware of other suitable uses for compositions and kitsprovided herein, and will be able to employ the compositions and kitsfor such uses.

EXAMPLES

The invention is further described in the following examples, which donot limit the scope of the invention described in the claims.

Example 1. Maximum Clot Lysis Rate Thrombolysis In Vitro by tPA/M5

The fibrinolytic and fibrinogenolytic effects of specific combinationsof tPA and M5 were studied in vitro in a human plasma milieu.

Materials

The mproUK that comprises a substitution of histidine for lysine atamino acid position 300 (Lys300→His) of pro-urokinase (M5) was preparedfrom E. coli by PxTherapeutics (Grenoble, France). Tissue plasminogenactivator (tPA) was obtained from Genentech (South San Francisco,Calif.). Human Fibrinogen, Kabi Grade L, was obtained from Chromogenix,Milan, Italy. Aprotinin and fluorescein isothiocyanate were from SigmaChemicals, St. Louis, Mo. Thrombin (ThromboMax, 100 NIH U per ml) wasobtained from Sigma (St Louis, Mo.). Clinical grade C1-inhibitor wasobtained from CSL Behring, Marburg, Germany. Human outdated blood bankplasma, pooled from four donors, was used in the experiments.

Note that various animal models have different sensitivities to humanpro-UK (see, e.g., Table 1 in Gurewich et al., J. Clin. Invest.,73:1731-1739 (1984), which is incorporated herein by reference in itsentirety. Thus, animal dosages cannot be used to determine humandosages, and the dosages described here are based on experience usingthe individual components in human tests. In vitro studies in humanplasma show that 2× as much M5 is needed than proUK for the same lysisrate. The monotherapy dose of proUK/M5 is known from Phase-3 studies andthe newly discovered mini-dose tPA plus the low dose of M5 in thecombination therapy methods described herein are based on this 2×factor.

Blood Clot Lysis Experiments

Fibrinolysis by M5 was studied in an inhibitor-containing plasma milieu.Blood clots were made by recalcification of 0.2 ml pooled blood bankplasma with 35 mM of calcium in the presence of a trace amount ofthromboplastin and a fluoresceinated fibrinogen (see Dmitry V, J BiolChem, 1996; 271: 2133-2138). The blood clots were then incubated for anhour at 37° C., followed by overnight incubation at room temperature.The following day, the blood clots were placed into 2 ml of blood bankplasma, followed by addition of tPA, M5, or the combination of tPA andM5. Clot lysis was monitored by taking 50 μl samples of the plasma atcertain time points and measuring fluorescence emission. Thefluorescence emission in the sample represents the amount of fibrindegradation products released from the blood clots. In some experiments,the volume of plasma was increased to 5 ml, and unlabeled fibrinogen wasadded to make up for the dilution of fluoresceinated fibrinogen. Inthose experiments, the end of blood clot lysis was determined visually.

Each blood clot lysis experiment was performed in triplicate. Graph PadPrism was used to prepare graphs and conduct statistical analysis.

The lysis curves were plotted as a percentage lysis of blood clots overtime. The 100% point was obtained from the mean of the highest readings.The base line reading was obtained at onset by subtracting the amount offluorescence shown by the plasma (˜15% of the full signal) to obtain thezero point. The time to 50% lysis for each experimental condition wasdetermined from the lysis graph and was used as the principal endpoint.

Determination of Remaining Fibrinogen after Blood Clot Lysis

After blood clot lysis was completed, a final plasma sample (1.0 ml) wasobtained for determining the remaining fibrinogen. Aprotinin (200KIU/ml) was added to the sample to prevent further proteolysis. Theremaining fibrinogen was recorded as the percentage of the baseline (BL)fibrinogen.

Fibrinogen was measured as a thrombin-clottable protein. After dilutionof the plasma sample with an equal amount of phosphate-buffered saline,200 μl of thrombin (1,000 NIH units/ml solution) was added. The solutionwas mixed gently, and incubated for an hour at 37° C., followed byovernight incubation at room temperature. The following morning, eachblood clot was wound onto a thin, long stemmed plastic transfer pipettetip, to which the gel adhered, and the serum content expressed bypressure against the test tube wall and then against a paper towel. Thewhite fibrin on the pipette stem was then placed in at least 5 ml ofsaline for at least an hour to allow diffusion of any remaining serumproteins. The fibrin was then peeled off the tip and placed into 1 ml of5% NaOH, boiled for one minute, and then kept at room temperature untilall fibrin had gone into solution. The protein in the solution wasmeasured spectrophotometrically at 280 nm.

Determination of the Shortest Time to Lysis by tPA or M5 Alone

The blood clot lysis experiments were performed as described above inthe presence of 1, 2, or 3 μg/ml of tPA. The lysis curves were plottedas a percentage lysis of blood clots over time, and the time used tolyse 50% blood clots for each experimental condition was determined fromthe lysis curve. The shortest time to lysis (from which the maximum clotlysis rate can be determined) was defined as the time at which there isno further dose-dependent shortening of the lysis time. The results of arepresentative experiment are shown in FIG. 1A and the shortest timeused to lyse 50% blood clots by tPA, was found to be 60 minutes when 3μg/ml of tPA was used. Thus, the maximum clot lysis rate is 50% lysis atone hour.

FIG. 1B shows the percentage of the remaining fibrinogen of the baselinelevel at the end of lysis for each tPA dose tested, ranging from 19% to45%. Thus, tPA alone caused 55%-81% fibrinogen degradation.

For M5, the blood clot lysis experiments were performed as describedabove in the presence of 10, 12.5, 15 μg/ml of M5. The shortest timeused to lyse 50% blood clots by M5, was determined to be 50 minutes,when 15 μg/ml of mproUK was used (FIG. 2A). Thus, the maximum clot lysisrate is 50% clot lysis at 50 minutes.

The percentage of the remaining fibrinogen of the baseline level at theend of lysis for each M5 dose, ranging from 25% to 55%, is shown in FIG.2B. Thus, M5 alone caused 45%-75% fibrinogen degradation.

Effect of C1-Inhibitor on Fibrinogenolysis by M5

To prevent fibrinogenolysis, 750 μg/ml of C1-inhibitor was added to theplasma prior to the addition of 10, 12.5, 15 μg/ml of M5 in the clotlysis experiments. The presence of 750 μg/ml of C1-inhibitor does notaffect the time used to lyse 50% blood clots by M5, which was still 50minutes (FIG. 2C). However, as shown in FIG. 2D, little fibrinogendegradation occurred in the presence of C1-inhibitor.

The C1-inhibitor experiment was not repeated for tPA, since C1-inhibitorhas already been shown to inhibit blood blot lysis by tPA (Tomasi S,PLos One., 2011; 6: e21999).

Maximum Clot Lysis Rate by a Combination of Mini-Dose tPA and Low DoseM5

To determine the lowest dose of tPA and M5 that is needed to achieve theshortest lysis time (and maximum clot lysis rate) when used incombination, the blood clot lysis experiments were performed usingvarious combinations and ratios of tPA and M5. The lowest doses of tPAand mproUK when used in combination to consistently achieve the maximumclot lysis rate were determined to be 0.2 μg/ml of tPA and 6 μg/ml ofM5. These doses corresponded to 6% of the tPA dose required to achievethe shortest lysis time plus 40% of the M5 dose needed to achieve thatwhen they were used alone in monotherapy. FIG. 3 shows the results of arepresentative clot lysis experiment, where the time used to lyse 50%blood clots by a combination of 0.2 μg/ml tPA and 6 μg/ml M5 was 53minutes, whereas the time used to lyse 50% blood clots by 6 μg/ml M5alone was 135 minutes and the time used to lyse 50% blood clots by 0.2μg/ml tPA alone was 225 minutes. These results demonstrate that a smalldose of tPA, e.g., 0.2 μg/ml, greatly shortened the clot lysis time byM5. This observation is consistent with tPA's function in initiatingfibrinolysis.

The results of ten representative clot lysis experiments are shown inFIG. 4A, using the combination (0.2 μg/ml tPA+6 μg/ml M5) (circle),which induced an average 50% lysis time of approximately 75 minutes. Atthis dose of M5 alone (triangle), the lysis time was 135 minutes, andtPA alone (square) induced a lysis time of 225 minutes. The findingsshow that a mini-dose tPA caused about a 45% shortening of the onset oflysis by M5. FIG. 4B shows the plasma fibrinogens at the end of lysis,expressed as percentage baseline (BL) fibrinogen. All experiments wereperformed in triplicate.

To test if tPA's function in the combination is limited to theinitiation of fibrinolysis, blood clot lysis experiments were performedusing four tPA-M5 combinations. Each tPA-M5 combination includes a fixeddose of 6 μg/ml of M5 and a different tPA dose selected from 0.2, 0.6,1.0, and 3.0 μg/ml. The time used to lyse 50% blood clots is about 48-60minutes for all four combinations tested and a tPA dose higher than 0.2μg/ml does not further shorten the time needed to lyse 50% blood clots(FIG. 6). These findings are consistent with tPA's function in thecombination being essential for the initiation of fibrinolysis but notcontribute to fibrinolysis beyond the initiation.

The average time used to lyse 50% blood clots in vitro, from multipleblood clot experiments were tabulated and compared. FIG. 7 shows thatthe mean time used to lyse 50% blood clots by the combination of 0.2μg/ml tPA plus 6 μg/ml M5 was 48 (±2.5) minutes (n=10); the time used tolyse 50% blood clots by 0.2 μg/ml tPA alone was 156 (5.3) minutes (n=5);for 6 μg/ml of M5 alone, it was 118 (±7.2) minutes (n=7); for 15 μg/mlof M5 alone, it was 48 (±1.6) minutes (n=9); and for 3 μg/ml of tPAalone, it was 55 (±5) minutes (n=6). The time used to lyse 50% bloodclots by a combination of 0.2 μg/ml tPA plus 6 μg/ml M5 is significantlyless than monotherapy of 0.2 μg/ml tPA alone or 6 μg/ml M5 alone (FIG.7). Although tPA and mproUK alone can achieve similar clot lysis time atvery high doses, e.g., tPA at 3 μg/ml or M5 at 15 μg/ml (FIG. 7),non-specific activation of plasminogen can occur at those doses andcause hemophiliac-like side effects.

Effect of Volume and C1-inhibitor on Fibrinogenolysis by the tPA and M5Combination

During fibrinolysis, mproUK is activated by plasmin and converted tomUK, which can then diffuse into the plasma. Confining proteolysis tothe clot becomes a function of plasma inhibitors, e.g., C1-inhibitor. Ina test tube, the limited plasma volume in vitro relative to the volumein vivo may be influential. Therefore, clot lysis experiments wereperformed under three conditions: (1) a control plasma volume of 2 ml,(2) an increased plasma volume of 5 ml, and (3) 2 ml plasma with 500μg/ml C1-inhibitor. Unlabeled blood clots were used for thoseexperiments and the time used to lyse 100% blood clots was determined tobe 75-80 minutes in all three conditions tested. In the standard 2 mlplasma volume, the tPA-M5 combination degraded 70% of fibrinogen,reflecting the rapid tcM5 generation rate by plasmin (FIG. 8). WhenC1-inhibitor was added, fibrinogenolysis was reduced to 45%, with 55%remaining fibrinogen (FIG. 8). A similar effect was observed in 5 mlplasma volume, probably reflecting dilution of tcM5 in the immediateclot environment (FIG. 8). This volume effect suggests thatfibrinogenolysis by the tPA-M5 combination may be further attenuated invivo where the plasma volume to clot ratio is considerably greater.

The more modest effect of C1-inhibitor when compared to FIG. 2D, arerelated to the more rapid fibrin-dependent plasmin generation induced bythe tPA-M5 combination compared with M5 monotherapy. It has beenverified by additional studies that the C1-inhibitor's ability toinhibit fibrinogenolysis by the tPA-M5 combination is reduced whencompared to its ability to inhibit fibrinogenolysis by M5 alone.C1-inhibitor is a relatively slow inhibitor and thus is less able toquench the more rapidly generated tcM5 from the more rapid fibrinolysisachieved by the tPA-M5 combination. Higher concentration of C1-inhibitormight be needed to sufficiently quench tcM5 generated from the tPA-M5combination.

The results of representative clot lysis experiments are shown in FIG.5A, using the combination (0.2 μg/ml tPA+6 μg/ml M5) (circle) inaddition to C1-inhibitor. C1-inhibitor (750 μg/ml) was added 30 minutesafter the addition of the activators. As shown in FIG. 5A, this did notinhibit lysis (circles), which on average was shortened to approximately30 minute, but did inhibit lysis by tPA alone (squares). FIG. 5B showsthe plasma fibrinogens at the end of lysis, expressed as percentagebaseline (BL) fibrinogen. As shown in FIG. 5B, the C1-inhibitorattenuated fibrinogenolysis. All experiments were performed intriplicate.

Fibrinogenolysis by the tPA-M5 Combination in the Absence of a Clot

To test the effect of the tPA-M5 combination on fibrinogenolysis in theabsence of a blood clot, the combination of 0.2 μg/ml of tPA plus 6μg/ml of M5 was incubated with plasma at 37° C. and samples were takenfor fibrinogen determination after 2-5 hours. As shown in FIG. 9, therewas no fibrinogenolysis for at least 3 hours, well beyond the durationof therapeutic thrombolysis. These findings indicate that the plasmingeneration induced by the tPA-M5 combination was fibrin-dependent andthat in the absence of a blood clot, this fibrinolytic combination doesnot induce plasminogen activation.

Example 2. Thrombolysis In Vivo by a Combination of tPA and M5

Male, mongrel dogs weighing 10-15 kg are anesthetized with pentobarbitalsodium and maintained breathing room air. Blood clots are formed from 1ml of native whole dog blood as described in U.S. Pat. No. 7,074,401, towhich radiolabeled fibrinogen (1.9 Ci, 0.75 mCi/mg protein) and thrombin(10 units) are added. After 20 minutes, the clots are washed with salinethree times and then cut into small (about 1 mm³) pieces and injectedthrough a 16-gauge needle into the femoral vein. After 15 minutes, ablood sample is obtained from a cannula in the contralateral femoralvein for the measurement of baseline radioactivity.

The dogs are divided into four groups and injected with (1) saline, (2)a bolus of 2-5 mg of tPA, (3) intravenous infusion of M5 (20 μg/kg/min)for 60 minutes, or (4) a bolus of 2-5 mg of tPA followed by intravenousinfusion of M5 (20 μg/kg/min) for 60 minutes. At intervals during theinfusions, blood samples were obtained and measured for radioactivityand fibrinogen. Time used to lyse blood clots is determined and comparedamong the four groups.

Example 3. Characterization of C1 Inhibitor and M5 in a Rat Model ofIntracerebral Hemorrhage (ICH)

The purpose of this study was to investigate the effect of M5 onintra-cerebral hemorrhage (ICH) volume.

Twenty adult, male Sprague-Dawley rats were used for the study. Ratswere randomly selected for use on surgical days. Rats were given aunique identification number by tail marking. Immediately prior toinitiation of surgery Cefazolin Sodium intraperitoneal injection (40mg/kg; Hospira 101C049) and Buprenorphine subcutaneous (1 mg/kg; ReckittBenckiser, 219202) were administered to the animals. While the rats wereunder isoflurane anesthesia (1.5% to 2%) with spontaneous respiration ina nitrous oxide/oxygen mixture (2:1), a small burr hole was drilled, anda 30-gauge 10 microliter microinjection needle (Hamilton, 700 series)was slowly lowered into the right striatum at the following coordinatesfrom the bregma: 0.0 mm anterior, 3 mm lateral, and 6 mm depth. During aperiod of 3 minutes, 3 microliters of saline containing 0.45 Ucollagenase VII-S(Sigma, St. Louis, Mo.) was injected. The needle wasleft in place for 2 minutes and then slowly removed over 5 minutes.Afterward, the scalp was stapled closed, and the rats were allowed torecover. The whole surgical procedure lasted about 20 minutes for eachrat. A heating pad (37±1° C.) is used to maintain animal bodytemperatures.

The C1 inhibitor and the test article (M5) were formulated prior todosing. Test solutions were kept on ice during the daily usage. Theremaining unused solutions were kept at −20° C. Immediately after abolus at 4 mL/kg (IV), animals were dosed by intravenous infusion (over30 minutes), starting at 15 minutes following ICH at 4 mL/kg. At 2 hoursafter the beginning of infusion, animals were humanely killed underisoflurane in 100% N20 inhalation. Brains were removed and cut in slicesaccording to a 2-mm rat brain matrix. Under standardized conditions,images of the brain slices were taken with a digital camera. Hematomasize was calculated by ImageJ software (available online atrsb.info.nih.gov/ij).

Two hours after hemorrhage induction, rats were sacrificed under deep(5%) isoflurane anesthesia (100% N20). Brains were removed and placed inphosphate-buffered saline (PBS) on ice. Brains were sliced into 7sections of 2 mm each and photographed for a visual assessment of thehematoma. A histological assessment was not conducted on the individualsections. Hemoglobin content was determined as a quantitativemeasurement of hemorrhagic volume. The hemorrhaged side (inclusive ofall 7 sections) was isolated from the normal side and placed into 1.5 mLof cold PBS. After 30 seconds of homogenization (manually with aPolytron PT2100), ultrasound was applied for 1 minute to lyseerythrocytic membranes. After centrifugation for 30 minutes (13000 rpm,4° C.), 200 μL of supernatant was added to 800 μL of Drabkins reagent(Sigma, St. Louis, Mo.) and allowed to sit for 10 minutes at roomtemperature. With use of a photometer, absorption rates were determinedat 540 nm, and hemorrhagic blood volumes were calculated for the injuredhalf of the brain on the basis of a standard curve. The standard curvewas generated by using eight naïve brain hemispheres from age and weightmatched (to the average study subject). These naïve brain hemisphereswere spiked with pooled blood from the same individuals at increasingvolumes from 0 to 192 μL. Statistical significance was assessed byanalysis of variance (ANOVA).

The timing at which the size of the hemorrhage was measured (2 hourspost hemorrhage induction) was determined from previous work optimizedat Biotrofix.

Rats were dosed as described with a bolus (4 ml/kg) of vehicle (saline)(4 ml/kg) followed immediately with a 30 minute infusion of vehicle, ora bolus of C1 inhibitor (200 U/4 ml/kg) followed immediately with a 30minute infusion of M5 (10 mg/4 ml/kg) at fifteen minutes post-ICH.

Clinical Observations and Survival

All animals survived the study period for this study. Animal #24 was notincluded for the analysis as there was insufficient hemorrhage inducedin this animal to be included.

Histological Determination of Hemorrhage Volume

M5 (immediately) following a C1inhibitor bolus injection was studied ina rat model of ICH. In this model, an intracerebral hemorrhage wasinduced by injection of collagenase into the right striatum of thebrain. Fifteen minutes post-injury M5 (at a dose of 10 mg/4 ml/kg) orvehicle was administered by a 30 minute intravenous infusion immediatelyfollowing bolus injections as described above. No significant difference(p=0.6899) was determined between the animals dosed with C1inh/M5 andthose dosed with saline/saline (FIG. 1).

Direct Hematoma Volume

As with the histological determination for hemorrhage volume, nosignificant difference (p=0.5194) was determined between the animalsdosed with C1inh/M5 and those dosed with saline/saline (FIGS. 10A and10B). FIG. 10A is a bar graph showing the hematoma volume followingintracerebral hemorrhage in a rat model. Intracerebral hemorrhage wasinduced by stereotactic injection of collagenase. Rats were dosed at 15minutes post injury with a C1inhibitor bolus injection followedimmediately with a 30 minute infusion of M5 (at a dose of 10 mg/4ml/kg). Hematoma volume was measured by hemoglobin content at 2 hourspost dosing. No significant difference (p=0.5194) was determined betweenthe animals dosed with C1inh/M5 and those dosed with saline/saline.

FIG. 10B is a bar graph showing the histological determination ofhemorrhage volume following intracerebral hemorrhage in a rat model.Intracerebral hemorrhage was induced by stereotactic injection ofcollagenase. Rats were dosed at 15 minutes post injury with aC1inhibitor bolus injection followed immediately with a 30 minuteinfusion of M5 (at a dose of 10 mg/4 ml/kg). No significant difference(p=0.6899) in hemorrhage volume was determined between the animals dosedwith C1inh/M5 and those dosed with saline/saline.

In this rat model of collagenase induced intracerebral hemorrhage, theadministration of C1 inhibitor/M5 administered 15 minutes post ICHinduction did not differ in hematoma volume or hemorrhage size relativeto saline/saline treated animals. Thus, M5 did not induce or augmentbleeding in this stroke model and thus should be safe to use in bleedingevents such as hemorrhagic stroke.

Example 4. Clinical Trial of a Combination of tPA and M5

Healthy male subjects, aged between 18 and 35 years inclusive, and witha body weight of at least 60 kg and a body mass index (BMI) between 18.5and 25 kg/m² inclusive are enrolled in the clinical trial. The subjectshave normal endogenous C1-inhibitor, α2-antiplasmin, and fibrinogenlevels, a negative serology for HIV, HBsAg, and HCV, and a negative testfor alcohol and drugs of abuse at screening and on study day 1. Thesubjects cannot have clinically significant abnormalities.

A subject is not included if he fulfils one or more of the followingcriteria: (1) the subject has a known or suspected inherited,congenital, or acquired disease or condition that affects thehaemostatic or coagulation pathways or that is associated with anincreased bleeding tendency; (2) the subject has a reasonable chance ofdeveloping a clinically significant bleeding event or a bleeding eventthat may go undetected for a considerable amount of time during thestudy, for example, the subject (a) has undergone major (internal)surgery or trauma within the last three months of the anticipated dosingday, (b) has an intestinal or cerebral vascular malformation, or (c) hasparticipated in high impact contact sports, such as kick-boxing, withintwo weeks of the anticipated dosing day; (3) the subject has receivedany systemically absorbed drug or substance (including prescription,over-the-counter, or alternative remedies) that is not permitted by thisprotocol prior to dosing without undergoing a wash-out period of atleast seven times the elimination half-life of the product; (4) thesubject has smoked tobacco in any form within three months of dosing, orhas ever smoked more than five cigarettes per day (or equivalent) onaverage; (5) the subject has received blood or plasma derivatives in theyear preceding the administration day; (6) the subject has lost blood orplasma outside the limits of the local blood donation service (i.c.Sanquin) three months prior to dosing; (7) the subject has a knownhypersensitivity to any of the investigational material or relatedcompounds; (8) the subject has a history of severe hypersensitivity orof an allergy with severe reactions; (9) the subject has a history ofsubstance abuse, including caffeine, tobacco, and alcohol; (10) thesubject has a condition or demonstrates an attitude that in the opinionof the investigator might jeopardize the subject's health or well-being,or the scientific integrity of the study results; (11) the subject ismentally or legally incapacitated to provide informed consent.

The enrolled subjects are randomly allocated to one of the followingtreatment arms:

(1) Injection of a bolus of 2.5 mg of tPA followed by intravenousinfusion of an mproUK, e.g., M5, for 60-90 minutes at approximately 80mg/hour (50% of the monotherapy dose);

(2) Injection of a bolus of 2.5 mg of tPA followed by intravenousinfusion of a placebo for 60-90 minutes;

(3) Injection of a placebo bolus followed by intravenous infusion of anmproUK, e.g., M5, for 60-90 minutes at approximately 160 mg/hour; or

(4) Injection of a bolus of 2.5 mg of tPA followed by a C1-inhibitor(Berinert®) bolus (e.g. 1000 EU (2 vials)), and intravenous infusion ofan mproUK, e.g., M5, for 60-90 minutes at approximately 80 mg/hour (50%of the monotherapy dose).

The dose for an mproUK ranges from 60-120 mg/hour. The C1-inhibitorbolus consists of 25-100 U/kg of Berinert® (based on body weight of thesubject). This study ends either when plasminaemia occurs or whensufficient data has been gathered.

Based on data gathered from this study, the overall safety andtolerability of the combination of tPA and mproUK such as M5 areevaluated. The effect of a mini-dose of tPA on mproUK-inducedcoagulation changes are assessed. The effect of a single dose ofC1-inhibitor on the overall safety and tolerability of tPA-mproUKcombination and its effect on tPA-mproUK-induced coagulation changes areassessed.

OTHER EMBODIMENTS

It is to be understood that while the invention has been described inconjunction with the detailed description thereof, the foregoingdescription is intended to illustrate and not limit the scope of theinvention, which is defined by the scope of the appended claims. Otheraspects, advantages, and modifications are within the scope of thefollowing claims.

1. A method of treating a subject with symptoms of a stroke or an acutemyocardial infarction (AMI) at a maximum rate of blood clot lysis andwith minimal associated hemorrhagic side effects, the method comprising:(a) identifying a subject who potentially had a stroke or AMI byobserving one or more symptoms of a stroke or AMI without determiningthe cause of the stroke or AMI; and (b) administering to the subject abolus of a first composition comprising less than 5 mg of tissueplasminogen activator (tPA) followed by an intravenous infusion of asecond composition comprising a pro-urokinase mutant (mproUK) infusedover 60 to 90 minutes at a rate of 60 to 120 mg/hour; wherein a maximumclot lysis rate is achieved with minimal associated hemorrhagic sideeffects.
 2. The method of claim 1, wherein the subject has symptoms of astroke.
 3. The method of claim 1, wherein the minimal associatedhemorrhagic side effects are determined as a level of fibrinogendegradation in the subject's blood of less than about 30 percent.
 4. Themethod of claim 1, wherein the maximum clot lysis rate is indicated ashaving been achieved by a Thrombolysis In Myocardial Infarction (TIMI)score of 2 or higher.
 5. The method of claim 1, wherein the maximum clotlysis rate is indicated as having been achieved by a lysis of about 50%of the mass of at least one clot in the subject achieved within 75minutes.
 6. The method of claim 1, wherein the pro-urokinase mutantcomprises a substitution of histidine for lysine at amino acid position300 (Lys300→His) of pro-urokinase.
 7. The method of claim 1, wherein thebolus comprises 2 to 4.5 mg of tPA.
 8. The method of claim 7, whereinthe bolus comprises 2 to 4.0 mg of tPA.
 9. The method of claim 7,wherein the bolus comprises 2 mg of tPA.
 10. The method of claim 1,wherein the second composition is administered as an intravenousinfusion at a rate of 60-90 mg/hour of the mproUK for 60-90 minutes. 11.The method of claim 10, wherein the second composition is administeredas an intravenous infusion at a rate of 60-80 mg/hour of the mproUK for60 minutes.
 12. The method of claim 1, wherein the administration of thesecond composition begins within five minutes after the administrationof the first composition.
 13. The method of claim 1, wherein the firstcomposition and the second composition together lyse 50% of a mass of atleast one blood clot in the subject in less than one hour.
 14. Themethod of claim 1, further comprising administering to the subject athird composition comprising a bolus of C1-inhibitor.
 15. The method ofclaim 14, wherein the third composition is administered to the subjectbefore the administration of the second composition.
 16. The method ofclaim 14, wherein the third composition is administered to the subjectat about the same time as the second composition.
 17. The method ofclaim 14, wherein the third composition is administered in an amountsufficient to establish a concentration of C1-inhibitor that is about500-750 μg/ml in the subject's blood.
 18. The method of claim 14,wherein the third composition comprises a bolus of 500-1500 mg ofC1-inhibitor.
 19. The method of claim 14, wherein the first compositionand the second composition together lyse the blood clots in the presenceof the C1-inhibitor with less than 30% fibrinogen degradation whencompared to monotherapy by either tPA or pro-urokinase alone. 20-38.(canceled)